How to Manage Migraine in Primary Care

Hope O'Brien, MD:
Welcome back to the National Headache Foundation's podcast NHF InSights, where we share the science and strategy for caring for people living with migraine. I'm today's host, Dr. Hope O'Brien. Today we are diving into episode two with the incredible Dr. Andy Blumenfeld. Last time we set the stage for why primary care clinicians and APPs are essential in migraine care. Today we're moving from the why to the how. Now, Andy, are you ready for a deep dive?

Andy Blumenfeld, MD:
Yeah. Sure, Hope. Episode one was a good warm up. And we got to talk a lot about the background, sort of the overview of how we do the management. But today we're going to focus more on the actual tools that clinicians need to achieve success.

Hope O'Brien, MD:
Let's start with something every primary care physician and APP wonders about: which patients should they manage by themselves, or which one should they refer to a specialist?

Andy Blumenfeld, MD:
Well, for the patients that have a low frequency or even a moderate to high frequency of episodic migraine, those types of patients should be managed in primary care. They certainly will all need an acute treatment. And if they're having frequent disabling headache, they will also need a preventative treatment. And the guidelines for that if they have at least four days a month of a significant headache, absolutely a preventative treatment should be offered. But that could even shift lower, that even if they had just two bad disabling days in a month, to think about preventative treatment. If these patients are not responding well to treatment, then I would think about referral.

Certainly, for patients who are at a high frequency or evolving into chronic migraine, that is the population that might be more reasonable to think about referring, and then obviously anyone with a question about a secondary headache disorder. So, there are a number of red flags to consider. And we use an algorithm called SNOOP that helps us work out these red flags. So, SNOOP has a long list of conditions that make you worry about the headache. So, for example, if there's a fever or weight loss or a history of HIV or an underlying cancer, that those are all risk factors for something structural in the brain causing the headache. If there’re focal neurological signs or symptoms, weakness, numbness on one side, an older patient who's starting with a headache for the first time, over 50, new onset of daily headache, this is definitely a red flag. A headache that has a very abrupt onset, thunderclap type of presentation, we're going to worry about that type of patient. And then postural changes, papilledema, these sorts of things must also be considered as red flags. So, if the patient has any of those, they certainly need to work up and may be appropriate for referral.

Hope O'Brien, MD:
Exactly. So, getting that diagnosis is going to be important, and getting them started early prevents progression and helps patients feel supported. They don't have to wait six months to see a neurologist before receiving relief, and especially if it presents as a garden-variety headache.

Andy Blumenfeld, MD:
Right. I mean, certainly as we discussed in episode one, we don't want to wait to start treatment because we don't want the brain to be exposed to the sensitizing effects of each migraine attack. So, we need to get treatment started early, and we want to use an appropriate treatment that's well tolerated. Because with any of these treatments, all we're doing is controlling the disease. We're not curing it. So, we need a treatment that the patient can stay on for the long term. So, always look not just at efficacy but also tolerability.

Hope O'Brien, MD:
Exactly. And I think one of the things that is important for individuals to recognize that are managing patients are those that have chronic migraine or they may have treatment failures, unusual presentations that come with their migraine. Or if you're thinking for your patient they may need infusions or neuromodulations or advanced therapies, that might be a reason why you want to refer to somebody who is a headache specialist.

Another thing that I encourage is having dedicated migraine visits, even if it's brief. And that's where you talk about your goals and preferences for these patients. So, Dr. Blumenfeld, can you talk a little bit about goals and how they may vary from patient to patient?

Andy Blumenfeld, MD:
I think it's very important, even at the first visit, to set the management goal that you're going to have with the patient. What I like to explain to patients is that we are walking down a road together, that this road has many branch points and barriers, and that we will need to maneuver around each of these, that this is a long-term process. It can't be done at one visit, and that we have a goal of migraine freedom, which at the high end of this pyramid is a crystal-clear day. But at the low end of the pyramid might just mean better control, where the patient is able to get to work and attend social activities. And we're going to layer treatments over time to try and get as close to these aspirational goals as possible.

And this is going to take time. And it's a partnering that involves a shared decision-making process. So, every step along the way the patient would be educated about the treatment options in terms of efficacy and tolerability and access and what the treatment involves. And then a decision is made between the provider and the patient about the best way forward. And that will lead to higher adherence.

Hope O'Brien, MD:
Absolutely. And I think it's important for patients to understand that the goal may not be clear migraine days, but maybe it's avoiding the emergency room. Or they may want to be able to travel or exercise without fear of having a migraine. So, when you know the goal, you can actually tailor the therapy, and patients are more likely to stick with the plan. Let's make tracking these goals simple. We're not asking people to be statisticians, right?

Andy Blumenfeld, MD:
No, I mean, really what you're doing is you're defining what a good day might look like. And it's a good day for that particular individual. And so, you will have a discussion with the patient about what their goals for treatment are. But then you can educate them about what you think the medications can do for them. We know from pivotal data for these medications that we can reduce the number of migraine days, number of headache days. A lot of the associated symptoms will come down. So, we can start to talk about all of those aspects with the patient.

Hope O'Brien, MD:
Absolutely. Then we can layer in a quick review of modifiable factors. So, whether or not they're taking in or consuming a lot of caffeine, ensuring that they're getting adequate, consistent sleep, not just staying up too late or sleeping in on the weekends. The importance of hydration. Exercise is key because it increases endorphins and helps patients tolerate pain better.

It's important for patients who do notice a menstrual pattern to their migraine that they intervene early to prevent that migraine headache from lasting a long time. Posture is important so going to physical therapy and working with them on improving posture. And obviously if they have symptoms of TMJ or teeth grinding addressing that as well. Now these aren't just optional wellness tips, but these recommendations really shift the neural sensitivity involved in migraine.

Andy Blumenfeld, MD:
Right. I mean if you leave those things unmanaged you may not see the full effect of your medications. So, you do want to set the foundation for your treatments to work well. I don't think you can rely just on these behavioral modifications, but they are a crucial factor in allowing us to optimize our care of the patient.

Hope O'Brien, MD:
Let's switch gears a little bit and talk acute therapy. And this is where patients often will experience with their own over-the-counter options.

Andy Blumenfeld, MD:
Sure. I mean patients who are often not well managed with preventative treatments might resort to taking over-the-counter analgesics, whether those are anti-inflammatory medications or things like acetaminophen. And these can be helpful, but if they’re used more than two days out of the week, they can actually cause a rebound pattern of headache where they will cause an escalation of the number of attacks and make the preventative medicine less likely to work.

So, it's actually very important to educate patients not to overuse these over-the-counter analgesics. A lot of times, patients don't think that these are really major medications. They might not even mention them to you unless you specifically ask and tease out how many days in the week are you actually taking medicines like acetaminophen, because this could be one of the reasons that they're doing badly.

Hope O'Brien, MD:
That's right. And many patients will think, oh, it's just an over-the-counter medication. It's safe, right? But if they're using it three, four, five days a week, then the medication can then cause this vicious worsening of the migraine cycle.

Andy Blumenfeld, MD:
Yes. I mean, there's certain prescription medicines that don't cause this rebound effect. Now, the triptans do have the same risk as the over-the-counter meds, and the ditans too. But if we look at the gepants, the gepants actually don't cause a rebound pattern. So, this becomes a very nice option to help us manage patients, giving them something that they can use when they need it, but not worrying about that two day a week rule.

Hope O'Brien, MD:
So primary care can prescribe these medications confidently. They don't require a subspecialist for titration. Now let's talk prevention because this is where the biggest gap exists.

Andy Blumenfeld, MD:
So unfortunately, many patients are not on preventative treatment even though they should be. Remember we're trying to control this disease, decrease the frequency of attacks, decrease the amount of time the brain spends in migraine. And certainly, if patients are having 4 or more migraine days in a month, they should be offered a preventative treatment. If you think about that, that's 4 days a month, 12 months a year, 48 bad days in a year, that prevention might have stopped from happening. So, we want to offer those types of treatment, but we should always take in account medications with high efficacy and high tolerability when we pick those.

Hope O'Brien, MD:
Absolutely. And when you think about that sort of push towards four or less headache days per month, I don't know how many of us could afford to, let's say, miss one day a week of work, right. So, I think it's important that we meet that goal of that four or less migraine days a month.

Andy Blumenfeld, MD:
Yeah. And almost 40% of migraine patients are having one bad day a week.

Hope O'Brien, MD:
Let's talk a little bit about the underutilization of preventive therapy and why that is.

Andy Blumenfeld, MD:
I think that a lot of this has evolved because of the side effects, that patients will discontinue treatments because they can't tolerate the side effect. So, this is a key factor, and you see this when you often offer medication to patients. The first question they ask is what are the side effects. It's a leading concern. And if they become tired or slow in their thinking or develop nausea, these are going to be inhibiting factors for them to take the medication.

Hope O'Brien, MD:
Yes. And I will tell you, only one third of those who qualify actually receive a preventive medication. So again, an extremely huge gap. Now PCPs and APPs are uniquely positioned to close this gap by initiating prevention early.

Andy Blumenfeld, MD:
Absolutely. The sooner you start, the better it's going to be. Obviously, you might have to work your way through step edits where payers might require a nonspecific treatment. When we say a nonspecific treatment, what we referring to are typically the generic-type medications that were found serendipitously to work for migraine, so things like the antidepressants and the anticonvulsants. These medicines do have efficacy and can help some patients, but a lot of times they also have side effects that can make it difficult for the patient to tolerate them long term. And the position statement that came out of the American Headache Society in 2024 basically encouraged us to move through these nonspecific medicines and get to the more specific treatments, which are drugs like the anti-CGRP medications sooner than later. And this is something that could be done in a primary care setting.

Hope O'Brien, MD:
Absolutely. We want to challenge the notion of step therapy. Start simple, escalate thoughtfully versus stratified care of jumping straight to advanced therapies. It needs to be really patient centered because when we choose a treatment that is patient centered, we have better outcomes and again higher tolerability. So, let's pivot to lifestyle as part of the multimodal strategy. We've talked a little bit about that in our last episode.

Andy Blumenfeld, MD:
Yeah, I mean certainly we could look at something like caffeine, which is a very common, used in the community. But if a migraine patient is having more than 200mg a day of caffeine, then they run the risk of developing caffeine withdrawal headaches. And they'll get into this rebound cycle where every day, they'll have a headache until they have their first cup of coffee. And they will then believe that more coffee is beneficial when in fact less coffee is beneficial. So there's this misconception. And this can often lead to medication overuse where they may switch to a medication like Excedrin that has a lot of caffeine in it. And then that may interfere with sleep, and we know that sleep deprivation is a strong trigger for migraine, one of the strongest triggers.

So, we want to really control all of these aspects. Exercise is key, but dehydration could be negative. And certainly, there are a lot of other triggers like stress. But then exercise is a very good way of helping to manage stress. So, all of this should be discussed, including posture and good sleep patterns, good sleep habits. These are important aspects of taking care of migraine patients.

Hope O'Brien, MD:
Absolutely. And lifestyle and behavioral modifications can amplify the effect of both acute and preventive therapy. Now we do have to address the elephant in the room and that's insurance barriers.

Andy Blumenfeld, MD:
So prior authorization is a huge barrier. Encouragingly, after the American Headache Society's position statement about using anti-CGRP medications as a first-line treatment for migraine prevention, this has started to shift. And insurance companies have removed a lot of the step edits. So we now see maybe only one step edit, as opposed to two before. And in some cases none, where you can go straight to the anti-CGRP medications. So, the step edits are actually improving. And it requires relooking at this. A lot of us are set in our ways because we ran into trouble early, well, early on, but the process has evolved.

Hope O'Brien, MD:
And that's been incredible. And it's important that documentation is accurate, documentation that the patient has, not just headache but migraine, those migraine days, it really has an impact on a person's day-to-day routine. And documenting that is very simple. It can also help improve that prior authorization process and approval.

Andy Blumenfeld, MD:
Right. And then also starting a treatment will help to be used for medical necessity documentation. So even if you're using a sample and the patient has benefit from that, you can use that to reinforce why the patient should be covered.

Hope O'Brien, MD:
Excellent. Andy, this has been a fantastic conversation. To summarize episode two, most patients with migraine can be managed in primary care. It's important to set goals with patients and keep tracking migraine simple. Acute therapy matters. Using over-the-counter medications should be used carefully, but we should also prioritize migraine specific options. Preventive therapy is underutilized, so start in patients with four or more migraine days per month. Lifestyle and physical factors can enhance outcomes. Insurance barriers are real, but simple documentation can help improve that process. Adjust treatment early. Switch or layer as needed.

This has been a really great experience working with you Dr. Blumenfeld. I don't know why it's taken this long for us to do this, but do you have any other closing remarks?

Andy Blumenfeld, MD:
Well, I think that as we think about using these treatments, when the patients come back for a follow up visit, it's always important to question how well the treatment is working. It's not adequate to say to the patient, are you doing better? Because most people will be doing a little bit better. You want to ask more specific questions like, after you took that acute treatment two hours later were you free of all migraine symptoms? Twenty-four hours later, will you still free of all the symptoms? When you're capturing headache days, make sure that you ask them how many days of the month are you headache free as a very important question for getting a very quick overview of how well your treatment is doing.

Hope O'Brien, MD:
Excellent. Andy, thank you as always for sharing your expertise. We should do this again sometime.

Andy Blumenfeld, MD:
Thank you.

©2026 National Headache Foundation. All Rights Reserved.

This episode of NHF InSights™ was supported by AbbVie. Content was developed independently by the NHF.

Resources:
1. SNOOP https://americanheadachesociety.org/research/library/red-flags-in-headache-what-if-it-isnt-migrainehttps://americanheadachesociety.org/research/library/red-flags-in-headache-what-if-it-isnt-migraine
2. AHS Statements https://headaches.org/insurance-pharmacy-coverage/ahs-position-statements
3. AHS Primary Care Resources https://americanheadachesociety.org/resources/primary-care
4. AHS Migraine Management Flowchart https://americanheadachesociety.org/resources/primary-care/migraine-flowchart